$4,000 SIGN ON BONUS!! ACO Community Health Worker (NAFM)

The ACO Community Health Worker provides comprehensive and coordinated management of patient care and resources through interdisciplinary collaboration to achieve optimal patient outcomes in accordance with the HCB care management team initiatives. Partners with the patient, family, and team to reduce the impact of the social determinants of health and improve patient's participation in wellness and early intervention prevention programs. Identifies emotional and physical barriers to participation and monitors the effectiveness of plans and resources. This person will support CHP’s mission, vision, and values and will adhere to compliance protocols as well as CHP’s policies and procedures.

ACO Community Health Worker Essential Duties and Responsibilities:

• Coordination of education, screening, brief intervention and /or facilitation of referrals to & from the ACO Clinical Care Manager to providers and community-based organizations and programs in accordance with applicable protocols for the following: Diabetes, Hypertension, Falls Prevention, Healthy Weight Management & Nutrition, Exercise, Depression/Stress, and Community & Social Services.
• Completes initial assessment and follow ups (as needed) on patients referred for interventions in accordance with appropriate policies, procedures, and protocols. This may require home visits or meeting patients in the community.
• Assisting patients in obtaining home health devices to support self-management and provide home safety assessments.
• Create Safety or Wellness plans for patients to help reduce risk for admissions.
• Support individualized goal setting to promote healthy behavior changes.
• Provide health education and empowerment, promotion of communication between patients and providers one-on-one and in groups which include like skills and general wellness groups.
• Provides assistance, advocacy and support (including connecting to appropriate resources) to patients relative to housing transportation, scheduling, interpreter services, finding a physician, health insurance and benefits, making and keeping appointments, and registering patients for community resources, programs and initiatives.
• Coordinates ancillary benefits for patients to assess and address psycho-social barriers that limit the patients' engagement including medication assistance, transportation, health insurance and interpreter assistance as necessary.
• Coordinates linkage to medical home (primary care doctor) for patients receiving services.
• Schedules the initial incoming appointment between PCP and community and conducts follow up (calls, emails, and/or electronic communication) to ensure proper connection to the primary care physician.
• Ability to refer for lab work and coordinate follow up based on protocols.
• Works in the community and/or clinical setting as part of the integrated health care team, as assigned.
• As part of the care coordination team maintains all forms, databases, and protocols; is responsible for the timely distribution of updated information.
• Supports a work environment that is responsive and sensitive to the needs of a diverse staff and clients and communicates effectively with patients and colleagues.
• Contributes and is an active part of a positive and professional team, supporting the mission.
• Documents in electronic health record, care management system or other assigned data collection tools in accordance with protocols.
• Participates in all scheduled departmental and team meetings as assigned by supervisor.
• Participates in on-site and off-site trainings, continuing education programs and in-service trainings to meet regulatory requirements and/or to meet the needs of the community.
• Position may be deployed to any area of the county to perform services or tasks.
• Meets with clinical staff and Community Health Workers routinely to assess needs and provides problem-solving and guidance and support.
• Generate reports, create stratification of patient registries of diagnostics, and facilitates provider follow up and referrals to community-based organizations.
• Performs any other duties as required by the ACO Clinical Care Manager.

Competencies: To perform the job successfully, an individual should demonstrate the following competencies:

• Self-disciplined, energetic, passionate, innovative, multi-tasker.
• A positive flexible team player that can follow a system and protocol to achieve a common goal, comfortable with change.
• Highly organized and well-developed oral and written communication skills.
• Demonstrates sound judgment, decision-making, and problem-solving skills.
• Able to maintain confidentiality with all aspects of information in accordance with practice, State and Federal regulations.
• Confidence to communicate clinical and community organizations and personnel.
• Advanced computer skills including Microsoft Office.
• Familiarity with medical records, systems, EMR's or other patient care systems.
• Familiarity with Athena, Allscripts, Meditech, Polaris or Midas is a plus.
• Ability to promote programs and services to community.
• Flexible hours.

Essential Skills and Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Experience:

• 2+ years’ experience in a community setting.
• Bilingual preferred.

Education and Training:

• High School Diploma or equivalency is required.
• Associates Degree preferred.
• At least 3 years of direct experience in health/human services in lieu of education will be considered.

License, Certification & Registration:

• CHW Certificate within 2 years (based upon access to training).

MA Driver's License with reliable transportation for travel to and from community sites and patient homes.